Thank you for choosing us for the continued care of your eyes. Please fill in red starred sections to make a quick appointment.If you would like a more tailored solution or you have been directed to this page, please fill in the rest of the form.

* Indicates required field

Name *

Mobile /contact number *

Email *

Address *

Medicare Card Number *

Medicare Reference number and expiry date. *

Health Fund (if applicable) *

Date and appointment time you would prefer *

When was the last time you had an eye examination? *

Less than 12 months1-2 years3-5yearsMore than 5 years

What is the main reason for your visit? *

Have you noticed any changes to your vision or eye comfort since your last visit? *

Have you been experiencing headaches or eye fatigue? Please provide details. *

Since your last visit, have you changed your occupation? *

Do you use a computer? *

How many hours a day?Desk topMultiscreenLap topBlue spectrum protected?

Are the spectacles we have on file for you the glasses you are currently wearing? *

Have you been happy with your current spectacles and have they been fulfilling your optical needs? *

Do you currently wear contact lenses?If not would you be interested in a free try to see how they feel and what they can do for you? *

If you have an eye condition that should be monitored, are a contact lens patient or if you have a family history of glaucoma or diabetes, do you wish to receive appropriate reminders at the Optometrist's request for monitoring and follow up? *

YesNo

We provide a recall service for all our clients which is based on their preferred method of communications. If you do not wish to receive this reminder please tick the box below: *

No

Following your eye examination, do you wish to receive relevant updates regarding eye health and a short customer satisfaction survey based on your experience in our practice (we welcome any comments that may help us improve our service)? *

PRIVACY STATEMENTOur practice respects your privacy and will comply with the Privacy Act and the Australian Privacy Principles when handling your personal information (including health information). We use your personal information to help us provide a tailored service for you. We may also use your personal contact information to send you information regarding eye health, eye care and eye wear, with your consent. We do not pass on your information to third party providers.